1. Medication Use Process
Part Two, Lecture # 6
PHCL 498
Amar Hijazi, Majed Alameel, Mona AlMehaid

2. Agenda Computerized Provider Order Entry (CPOE)
Pharmacy Information System (PIS)
Automated Medication Dispensing Devices and Robotics
Bar Code Electronic Medication Administration Record (BCMAR)
Smart Intravenous Infusion Pumps
Electronic Medication Reconciliation

3. References e-book, Chapter 18 Electronic Health Records, Chapter 15
content/uploads/SmartMedicationDeliverySystems_FullReport1.pdf

4. Medication Management and Technology
Medication Reconciliation
LIS
RIS
Problem List
CDSS
Medication Order
Formulary Inventory
Selection, Preparation and Distribution
Automated Dispensing Cabinets
Robotics
Pharmacy Processing
BCMAR
Monitoring and Intervention
Patient Portal
Medication Administration
CPOE
NIS
PHR
PIS
Clinical Data Repository

5. Computerized Physician Order Entry
Refers to any system in which clinicians directly enter medication orders (and, increasingly, tests and procedures) into a computer system, which then transmits the order directly to the pharmacy. These systems have become increasingly common in the inpatient setting as a strategy to reduce medication errors. A CPOE system, at a minimum, ensures standardized, legible, and complete orders and thus has the potential to greatly reduce errors at the ordering and transcribing stages (AHRQ)
Recommended by IOM in 1991
Can decrease serious inpatient medication errors by 55 %

6. Doctors will enter the prescription
The electronic prescription is sent to the Pharmacy RX

7. fluoxetine (as hydrochloride) 20mg capsules
Fluoxetine belongs to SSRIs, and has the following interaction information for patient’s current mediciations:
Aspirin
increased risk of bleeding when SSRIs given with aspirin

8. Advantages of CPOE Legibility Including all order components
Reduce care variation
Generation of alerts
Specific alerts
Global alerts
Drug allergy
Inappropriate dosing
Inappropriate route
Inappropriate cumulative dose
Specific alerts:
Alerts generated when for e.g. the ordered medication might be contraindicated because of Allergy
Global Alerts:
Still specific to the patient but more general for e.g. reminders of laboratory results and/or number of medications the patient is on

9. Advantages of CPOE, Cont’d
Age contraindications
Conditions contraindication
Drug-diagnosis contraindication
Laboratory warning
Corollary orders (monitoring)
Pre-intervention orders
Audits
Reduction in cost
e.g. of corollary orders:
When the doctor orders gentamicin the system reminds the doctor to order gentamicin level
Theophyllin IV and Theophyllin level
Insulin and Glucose monitoring
Pre-intervention orders:
e.g. reminder to check creatinine level before ordering a pyelogram procedure

10. Challenges to CPOE Ordering delay in emergency situation Alert fatigue
Substantial workflow changes
The implementation process
More information is required to be entered:
Co-signature
Clinical history
Diagnosis

11. Factors Contributing to improved CPOE Utilization
Top down commitment to mandate CPOE use in the hospital
Plan for resistance
Scrutinize workflow
Select a champion
Order sets development
Training and refreshment training
Measure success
Manage expectation
Time
Computers do not take care of patients

12. Pharmacy Information System
Is a complex computer system that has been designed to meet the needs of a pharmacy department. It will allow pharmacists to supervise and have inputs on how medication is used in a hospital

13. PIS Functions and Features
Inpatient order entry management and dispensing
Outpatient order entry management and dispensing
Labels and label routing
Inventory management
Products differentiation
Order sets and protocols
Clinical monitoring
Manufacturing and compounding
Intervention management
Connectivity with other systems
Fill lists ‘cart fill’
Pricing, charging and exchange

14. PIS General Considerations
User interface
Outpatient and inpatient profile
Flexibility in sorting and selection of orders
Display of complete profile
Security and authority
Data retention

15. Automated Medication Dispensing Devices and Robotics
Centralized
Mainly for inpatient setting
A large robot that has access to the most frequently used medications
Performs labeling of medication
Place medication in patient specific drawers
Handles refills of ongoing orders
7A7E

16. Automated Medication Dispensing Devices and Robotics, Cont’d
Decentralized
Used for inpatient
Located near the patient care area
Provides a check on the person requesting medication for a specific patient
Has a billing interface

17. Automated Pharmacy Drugs Dispensing System
It Consists of: Software. Hardware. And it interfaces with Hospital Information System to get Patients and orders Data
It Consists of Tow major Parts:
Software and Hardware
Interface with Hospital Information System to get Patients and orders data

18. Automated Pharmacy Drugs Dispensing System
Replace manual distribution with:
A Fully Pharmacy Automated System
Automated Pharmacy Drugs Dispensing System
HIS: Hospital Information System
HIS
Console
Interface

19. OPP Robotics

20. IV Preparation ROBOT

21. Packaging Machines ATDPS
Integrated packaging machines with all software and devices in the pharmacy.
Billing From all Stations on a regular basis
Bar- code generated automatically for every backed tablet.

23. Bar Code Medication Administration
BCMA is a clinical information module residing within each facility’s health
information system. The module is accessible from computer work stations and mobile computers on each nursing unit. From work station computers staff may view medication order reports and look up medication administration information. The module is accessed via wireless connectivity from a laptop computer mounted on a wheeled medication cart. Each cart has either a wireless or tethered handheld scanner. The carts have a number of individual patient medication drawers, corresponding to the number of patients served per cart

24. BCMAR Diagram Physician order CPOE Nurse Administers med
Pharmacy Verification
Due med is selected and scanned
Medication Dispensing
Patient’s med list displays
Nurse Verification
Nurse Confirms patient’s ID

25. Bar-Code
Unique key for every drug
Eliminates Medication errors

26. BCMAR Advantages Legible recording of meds
Guidance of medication administration
Positive patient identification
Assessment reminder
High alert medication verification
Discrepancies reporting
5 and 8 Rights

27. BCMAR Challenges Cost associated with Bar Code arm bands or RFID
The ability to have Bar Coded unit-dose available
Workflow changes
Adhering to procedures
Portability of equipment
workarounds

28. Factors Contributing to improved BCMAR Utilization
Consider nursing workflow and medication management process
Analyze the product design i.e. human-computer interface to prevent work around
Scrutinize the software to ensure the system is simple to use
Device must be ubiquitous
Assess integration
Communication
EMR
Bar Code Reader
Medication Dispensing Machine
Physician
Pharmacist
Nurse

29. Smart Intravenous Infusion Pumps
Intravenous (IV) infusions have been identified as frequent contributors to medication errors, and the injuries that result from them. This is not surprising given that approximately 90% of patients receive medications via the IV route, and IV pumps are responsible for the majority of medication deliveries
General infusion pumps were designed to improve accuracy and continuity of IV infusions by allowing nurses to program an hourly rate and volume. However, studies have shown that these devices are involved in 35-60% of the estimated 770,000 Adverse Drug Events (ADEs) that occur each year in the US

30. Smart Intravenous Infusion Pumps
More specifically, the Institute of Medicine estimated that two-thirds of preventable deaths are due to infusion therapy and are attributable to manual programming errors when using infusion pumps

31. Smart Intravenous Infusion Pumps
To address high incidence of infusion errors, manufacturers have developed smart pumps. Smart pumps have Dose Error Reduction Systems (DERS), which include hospital-defined drug libraries with dosing limits and other clinical advisories integrated into the system (i.e., smart pumps)

32. Smart Pumps Advantages
Detect and correct infusion programming errors
Comparing entered dosage values with predefined libraries set by the institution
“Soft” or “Hard” limit warning
Reduce errors associated with miscalculated doses

33. Smart Pumps Challenges
Longer process
Selecting clinical area
Selecting drug name and concentration (if not Bar Coded)
Staying up-to-date with emerging devices
Correctly maintaining and updating the devices
Requires a complex implementation process
Requires integration with the medication administration process

34. Bar Coded Smart Pumps Workflow

35. Electronic Medication Reconciliation
Another type of medication error that occurs is at the transition of care
JCI has mandated that all healthcare organizations that prescribe medication must “accurately and completely reconcile medications across the continuum of care
Electronic MedRec (eMedRec) uses Health formation Systems (HIS) to access and integrate electronically stored patient medication data
To support the development of the electronic Best Possible Medication History (eBPMH) and the detection and resolution of discrepancies
Can be integrated with other systems such as computerized provider order entry (CPOE)

36. eMedRec Advantages Generate the best possible medication lists (BPMHs)
Electronically support human MedRec processes providing electronic sources of data
Providing electronic tools for comparing lists and
Detecting and resolving medication discrepancies
Improved standardization of documentation
Improved legibility of information
Improved communication between providers
Improved accessibility of documentation